Kokoszki v. Playboy Enterprises, Inc., Case No. 2:19-cv-10302-BAF-RSW (E.D. Mich.

REQUEST FOR EXCLUSION FORM

In order to exclude yourself from the Settlement, you must mail your request for exclusion postmarked by
July 24, 2020.
You can exclude yourself from the Settlement by completing the form below and mailing this form to the
Settlement Administrator at the below address:

Playboy Magazine Settlement

c/o JND Legal Administration
PO Box 91350
Seattle, WA 98111

I. CLASS MEMBER INFORMATION

Name: ____________________________________________________________________________________

Mailing Address: ___________________________________________________________________________

City: _____________________________________________ State: _________ Zip Code: _________________

Name(s) of the Playboy Publication(s) to which you were a subscriber between January 1, 2016 and July 30,
2016:

__________________________________________________________________________________________

II. CERTIFICATION

I affirm that I would like to be excluded from the Playboy Magazine Settlement, Kokoszki v. Playboy Enterprises,
Inc., Case No. 2:19-cv-10302-BAF-RSW. I understand that by excluding myself, I will not receive a pro rata
share of the Settlement Fund.

Signature: _________________________________________________ Date: __________________________